RADY 410 Case Presentation:

Uterine Artery Arteriovenous Malformation in Postpartum

Hemorrhage

Henry Stiepel, MS44 September 2019

Patient history and workup

• A 40-year-old G8P5126 female presented to the hospital with severe vaginal bleeding and an estimated 2000mL of blood loss at home. • The patient had a history of ectopic pregnancy, placenta previa, and dilatation

and curettage.

• Three weeks prior, she had a vaginal delivery of a term infant resulting in post-partum hemorrhage, with 2700mL of blood loss. • The hemorrhage was controlled with uterotonics and the placement of a bakri

balloon.

• She stabilized and was discharged home on postpartum day two.

Patient history and workup

• In the emergency department, her hemoglobin dropped from 12 g/dL to 10 g/dL.

• Interventional Radiology was consulted, and they elected to perform bilateral internal iliac arteriograms via a radial approach. • Sub-selection of the uterine arteries would also be performed if possible.

Iliac Artery Anatomy

https://web.duke.edu/anatomy/Lab09/Lab9.html

• Digital subtraction angiography of the left internal iliac artery. • The beginning of a nidus is

noted in the uterine artery. • A nidus is a tangle of

abnormal blood vessels.

Imaging Studies: Left Internal Iliac Artery Arteriogram

Iliac artery catheterization

Uterine artery nidus

InternalIliac artery

• Sub-selection of the uterine artery demonstrates a large, tortuous uterine artery with the presence of a nidus.

Imaging Studies: Left uterine artery arteriogram

Tortuous uterine artery

Uterine artery nidus

• Brisk venous filling is noted around the nidus.

Brisk venous filling

Uterine artery nidus

Imaging Studies: Left uterine artery arteriogram

• Early opacification of the internal iliac vein is seen. The presence of a nidus with early opacification of the congruent vein confirms a uterine artery arteriovenous malformation (AVM).

Early opacification of the internal iliac vein

Brisk venous filling

Imaging Studies: Left uterine artery arteriogram

• The right uterine artery has tortuous, spiral arteries that are associates with a post-partum, enlarged uterus.

Spiral uterine artery

Right uterine artery catheterization

Imaging Studies: Right uterine artery arteriogram

Patient treatment: Left uterine artery embolization

• Thick glue was used to embolize the AVM in the left uterine artery due to its brisk flow and large size.

• Post-embolization left uterine artery arteriogram shows obliteration of the nidus.

Left uterine artery catheterization

Uterine artery nidus no longer filling, post embolization

Patient treatment: Right Uterine Artery Embolization

• The right uterine artery was empirically embolized using 500 – 700 µm non-absorbable particles (Embosphere, Merit Medical, South Jordan, Utah, US).

• Stasis of blood flow within the right uterine artery confirmed on repeat arteriogram of the uterine artery.

Uterine artery catheterization

Stasis of blood flow

Patient outcome

• At her outpatient follow up two weeks after the procedure, she did not report any repeat bleeding or passage of clots.

• The patient did not require a hysterectomy due to the obliteration of the AVM.

Discussion: Epidemiology of uterine artery AVMs

• Arteriovenous malformations are abnormalities of the vascular system that consist of a tangle of abnormal blood vessels forming a nidus that allows for an abnormal, brisk communication between arteries and veins.

• The prevalence of uterine AVMs is currently unknown, and estimates are based on reviews of the literature.• There are little more than one-hundred reported cases [1].

Discussion: Symptoms of uterine artery AVMs

• Uterine AVMs typically present with symptoms such as menorrhagia, postpartum hemorrhage, and spontaneous abortions [2].• Symptoms may be similar to fibroids, endometriosis, and adenomyosis.

Discussion: Types of uterine artery AVMs

• Primary/Idiopathic • Congenital developmental abnormalities [3].

• Secondary/Acquired • Caused by reactive angiogenesis, pregnancy related changes, uterine

procedures, or trophoblastic invasion [3].

• Uterine instrumentation, such as dilatation and curettage or surgery, is considered one of the main causes of acquired uterine AVMs [1,4].• This is because they cause inflammation and reactive angiogenesis.

• Diseases associated with the formation of uterine AVMs include endometrial carcinoma, cervical carcinoma, and trophoblastic disease [3].

Discussion: Diagnosis of uterine artery AVMs

• The gold standard for the diagnosis of uterine artery AVMs is digital subtraction angiography [1].

• Color doppler ultrasonography can also demonstrate the presence of uterine artery AVMs [5].• Patients complaining of symptoms in the non-acute setting may benefit from

an initial non-invasive evaluation.

• Computed topography angiography and magnetic resonance angiography may also be used for procedural planning [5].

Discussion: Treatment of uterine artery AVMs

• Uterine artery embolization (UAE) is the gold standard for treatment of uterine artery AVMs [3].• Trans-arterial embolization is a minimally invasive technique that can quickly

control even catastrophic hemorrhage and effectively treat the lesion, while preserving the uterus.

• Prior to UAE, the gold standard was hysterectomy.

• Embolization of the bilateral uterine arteries should be the preferred approach, since uterine AVMs most likely have feeding vessels from both sides [3].

Discussion: Treatment of uterine artery AVMs

• The type of embolic agent chosen by the interventional radiologist performing the procedure varies and depends on the size and flow rate of the shunt. • Another important factor is the operator’s comfort and experience level with

the different agents.

• Gelfoam is commonly used since it is reabsorbed by the body in 10-14 days and can maintain fertility in reproductive age women [6].

Summary

• Uterine artery AVMs are rare, but can result in serious complications, including severe menorrhagia, spontaneous abortions, and postpartum hemorrhage.

• Uterine AVMs are most commonly acquired and are associated with instrumentation of the uterus (such as dilatation and curettage).

• Diagnosis can be made by digital subtraction angiography or color doppler ultrasonography.

• Treating with uterine artery embolization can prevent the need for a hysterectomy and preserve fertility.

References

1. Grivell, Rosalie M. et al. “Uterine Arteriovenous Malformations: A Review of the Current Literature” Obstetrical and Gynecological Survey 2005;60(11):761-767

2. Fleming, H et al. “Arteriovenous malformations of the Uterus” Obstetrics and Gynocology. 1989;72(2);209-213

3. Kim, Taehwan et al. “Management of Bleeding Uterine Arteriovenous Malformation with Bilateral Uterine Artery Embolization” Yonsei Medical Journal. 2014;55(2):367-373

4. Rosen, Todd. “Placenta Accreta and Cesarean Scar Pregnancy: Overlooked Costa of Rising Cesaren Section Rate” Clin Perinatol 2008;35:519-529

5. Shim, Da Joung, et al. “Uterine arteriovenous malformation with repeated vaginal bleeding after dilation and curettage” Obstetrics and Gynecology Science. 2019;62(2):142-145

6. Vilos, Angelos G. et al. “Uterine artery embolization for uterine arteriovenous malformation in five women desiring fertility: pregnancy outcomes” Human Reproduction. 2015;30(7):1599-1605